The technology revolution which fueled the decline in birth rate has also been responsible for ushering in the era of technology of prenatal sex determination tests (SDTs) since 1970s. Initially, it was through amniocentesis which soon gave way to the relatively safer non-invasive technique viz. ultrasonography. This was lapped up by people at large so enthusiastically that it seemed that this fulfilled a long felt need of people. Very soon, ultrasound clinics mushroomed all over India, particularly in north India. These became a promising money earning venture.

Eventually, there was a public outcry against the deplorable practice of female feticide. With the pressure from gender and health activists building up and census (1991) showing further decline in female:male ratio, the Government of India enacted PNDT (Prenatal Diagnostic Techniques - Regulation and Prevention of Misuse) Act in 1994. It provided for regulation of the use of prenatal diagnostic techniques for the purpose of detecting genetic disorders and for prevention of misuse of such techniques for the purpose of prenatal sex determination leading to female feticide[1] .

However, alarm bell started ringing for planners with census 2001 results which revealed a sex ratio of 933 females: 1000 males which failed to improve much above the previous census data of 927 females to 1000 males. The situation seemed to have gone out of hand in north India where the ratio was 727:1000. Disturbed by this scenario strict enforcement of PNDT Act was contemplated by the state governments, in North India. There were numerous raids on ultrasound clinics. Registrations of many clinics were cancelled in Punjab, Haryana and Chandigarh[2] .

Against this background the present study was undertaken with following objectives:

to estimate the extent of the practice of sex determination tests in the study area.

to ascertain the profile of the couples who resort to SDT.

to ascertain the knowledge and attitude of the respondents regarding SDT.

Material and Methods

A female social worker was recruited for the study. A proforma was developed of the study and was finalised after pretest/ pilot study. A sample size of 205 pregnant women aged 18-29 years was worked out at 95% level of confidence and with 5% margin of error. A reported prevalence of 16% for SDT[3] was used for calculating the desired sample size (t = 1.96, d = 05, p = 0.16, q = 0.84). For getting this sample size it was proposed to survey about 16000 rural population. For this, 11 road side villages were randomly selected from a purposively selected community development block in north India.

A house to house survey was conducted in the study villages to enlist the pregnant women by asking 18-29 years old respondents about their last menstrual period. All pregnant women thus enlisted were asked whether they had undergone SDT or not. Those who had not undergone SDT were surveyed for their knowledge and attitude towards SDT. They were followed every month till 5th month of their pregnancy to ascertain whether they resorted to SDT or not.

Those who opted for SDT were interviewed to get the details about time, reason, agency and money spent etc. pertaining to SDT. They were also followed up for four months to ascertain the action taken by them after the SDT. Manual analysis of the data was done. Consent of the respondents was taken for the interview. The project was approved by the institute ethics committee before execution.

Results

The project was conducted during 2002-2003. Overall, 1162 women aged 15 yrs. - 29 yrs. were screened in 11 villages (population, 16475)[2] for their pregnancy status through questions pertaining to their menstrual status during a house to house survey by a female social worker. Two handred women (17.2%) were enlisted as pregnant. Of them, maximum (118;59%) were aged 21-25 years. Some (26;13%) were aged less than 20 years. Literacy rate was 73% (5% were graduates). All except 3 (2 service; 1 skilled worker) were housewives. Husband's literacy rate was 86% (8% graduates). Casual labour was the occupation of maximum (42%) males. Some were in service (8%), some had small business (17%), some were skilled workers (16%) and 19% were farmers. Majority lived in joint families (74%). Castewise, one fourth were Hindu high caste, 65% were Hindu - backward or low caste and the rests were Sikhs (1.5%) or Muslims (4.5%). Half of the families were in low social class, rest were in middle (45%) or upper middle class (5%).

Majority (134;67%) reported that they had some test done during this pregnancy; 119 had some laboratory test and 45 had ultrasound test done (multiple responses were also there). In 54(27%) cases these tests were done in govt. hospitals and in the rest in private hospitals. Twenty six women (13%) confessed that they did it for sex-determination. Other reasons for getting the test done were confirmation of pregnancy, hemoglobin, doctor's advice. One fourth of them spent Rs. 300/- or more on the test. Rest spent less (6% free-govt. health centre).

Majority of the respondents (169; 84.5%) desired a two child family. Fifteen (7.5%) desired 3 children and 4% opted for a one-child family. Others did not respond. More than half of them (176; 55%) wanted at least one son (9% wanted two sons). Most of them (181; 90.5%) wanted at least one daughter. Only two wanted 2 daughters. Disadvantages of having only daughters were told as - 'nobody to look after in old age' (24%) 'nobody to inherit' (4%), 'nobody to carry forward family name' (18%) and 'taunts by in-laws' (8%). Most (94%) said that it was necessary to have sons. When asked 'what should be done to get a son'... 19 (9.5%) said that a test could be done. Some recommended prayers (2.5%) or special medicines (2.5%).

Most of them (95%) knew that it was possible to know the sex of the fetus in the womb by ultrasound test. They told that this test was available in private clinics only. Majority (70%) told that the test cost Rs. 500/- or more. Sixty four pregnancy (68%). Some told about 5th month (12%). Rest did not know about it. Most of them said that going for SDT was not a good practice (83%) and was a crime. Ten per cent said it was a good practice. Rest did not know about it.

Twenty six (13%) women admitted that they had SDT done. Of them, 18 had daughters only (10 iwth one child, 6 with two daughters, one each with three and four daughters). Rest had no kids (3), one son (1), one son / one-daughter (2) and one son / three daughters (2). (In 23 cases they were told that it was a male fetus; in 20 cases a male child and in one case actually a female child was born. In two cases the pregnancy ended in spontaneous abortion). Of the three cases, where the sex of the fetus was declared as female, one continued with the pregnancy, while in two cases female feticide was done. In one of these cases there was one and in the another there were two daughters in the family. The period of gestation was 4 months and 5 months in these cases. Bleeding, pain and weakness was reported after the procedure. In both the cases family members agreed with the decision.

Following are some of the responses given by our respondents during the interviews - (when asked about the status of daughters in the family).

'Once a daughter is born she can't be thrown away.'

'Problem - if parents have to go out at night to attend some emergency, leaving behind daughters'.

'Daughters needs more careful rearing - lest they go astray'.

'Daughters bring poverty. All the money is spent for dowry. If sons are also there, daughters do not pinch'.

'Daughters are valued only if son is there'.

'The lamp of house remains lighted (if son is there). 'son is needed to run the household'.

'The home must remain open (after daughters go to in-laws). With sons the door of home remain open.'

'In landlord families one can't do without sons'. 'With sons the family tree (climber) grows'. 'People care for the family only if son is there'.

I' have a son - one must have two - one (earning) hand is of no value - two must be there'.

'Balance is OK if both (son & daughter) are there'.

'With sons one's own home is run and with daughters other's home'.

'Someone is needed to guard the house'.

'Someone own must be there in family to celebrate festivals' (daughters go away).

'If the first born is a son - one stops worrying'.

'All family traditions/customs/rituals are dependent on sons.'

However, some of the respondents reflected modern outlook towards girl-child. e.g. 'Nowadays, everyone is equal. It is only in your mind (the preference for sons)'.

One respondents also told about SDT related issues as well as about indigenous ways of predicting sex of the fetus.

'In Rajput families if the first child is a girl everyone becomes alert... and go for SDT in next pregnancy".

'Sometimes doctors give wrong result. They just earn money...'

'Private doctors change more money (for SDT) since they have to do it on the sly'.

'If there are 3-4 daughters - one must go for test. In such cases they are helpless - there is no choice'.

'Nowadays they don't tell (the sex of the baby) and charge extra to do abortion just to get more money even if it is a male fetus'.

'Nowadays everyone is equal. On growing old neither daughters care for you nor sons'.

'People don't want daughters. The females are getting lesser. How will boys get married'?

Discussion

Prenatal diagnosis tests diagnose the results of conception. These are done to detect genetic or chromosomal aberration of metabolic disorders. The use of these technologies purely for sex determination is a by-product of tests for the detection of fetal abnormalities. Amniocentesis was first introduced in India in 1974 at AIIMS to detect foetal abnormalities. By 1975, it was known that the test was being used for conducting sex selective abortions. The AIIMS stopped performing the tests in 1979, when the Govt. of India banned the misuse of medical technology for sex determination in all Govt. institutions. Then came reports from Amritsar and Bombay of private gynaecologists offering the tests. This marked the widespread beginning of privatization and commercialization of the technology which became very popular 4 in rural north India due to strong son preference in this region[4],[5]

Data show that between 1978 and 1982, about 78,000 female fetii were aborted after sex determination tests, a number of them in the second trimester. A study conducted in Mumbai revealed that in less than 10% of the cases, these tests were carried out for detection of genetic defects[6] . A population based study conducted in rural North India revealed that 11% of women resorted to sex determiination test (SDT)[7] .

Our study revealed that despite the ban on SDT the practice still continues in north India through private clinics. Even female feticide is practiced. Most of our respondents favoured sons and daughters were seen as a burden. This 'son syndrome' is a reflection on the low status of females in our society. In Maharastra also SDT/ female feticide was reported despite the ban[6] . The fact that most of our respondents were aware about the availability of the test in private sector and that many infact underwent the test indicates that this is a felt need of the society. Contrasted with this is the PNDT Act of the Government. This disparity/contradiction between the Govt.'s intent and popular public demand need to be resolved at the earliest.